New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations.
To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders.
We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey.
The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn .
An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process.
PREPARE-2023CN018.

Hiatal hernia is the passage of digestive tract portions into the posterior mediastinum through a defect in the esophageal diaphragmatic hiatus. By guidelines, the diagnosis uses first-level radiographic investigations such as chest X-ray and contrastographic methods. As of today, use of ultrasonography in the suspicion/diagnosis of hiatal hernia is not standardized although it shows advantages such as not using ionizing radiation, which is essential in the small pediatric patient. We report the case of a little 4-month-old patient who came to our attention for dysphagia, vomiting and borborygmus to whom Type II hiatal hernia was suspected by ultrasound investigation, later confirmed by guidelines approved methods.

Paraesophageal hernias are often asymptomatic, but when symptomatic they should be fixed laparoscopically. A cruroplasty of the diaphragmatic pillars is performed and a fundoplication is usually performed at the time. However, there are times, especially in emergency cases, where it is not always possible to perform a fundoplication. We hypothesized there would be no difference in outcomes whether or not a fundoplication is performed as part of a paraesophageal hernia repair.
A literature review of available clinical databases was performed using PubMed, Clinical Key and Google Scholar. Our search terms were: \"paraesophageal hernia\" \"paraesophageal hernia repair\" \"fundoplication\" \"emergency surgery\" \"no fundoplication\" We excluded studies that were in languages other than English, abstracts and small case series.
Our search criteria yielded a total of 22 studies published between 1997 and 2020. There were a total of 8600 subjects enrolled into this study. The overall pooled prevalence of fundoplication were estimated as 69% (95% CI: 59%-78%). In patients who underwent fundoplication, the risk of gastroesophageal reflux disease (GERD) was reduced as compared to patients who did not undergo fundoplication (RR: 0.64, 95% CI: 0.40-1.04, p = 0.069, I2 = 47.2%). A similar trend was also observed in recurrence (RR: 0.53, 95% CI: 0.27-1.03, p = 0.061, I2 = 0.0%) and reoperations (RR: 0.25, 95% CI: 0.02-2.69, p = 0.25, I2 = 56.7%). However, patients who underwent fundoplication had an increased risk of dysphagia (RR: 1.68, 95% CI: 0.59-4.81, p = 0.83, I2 = 42%).
There is a higher rate of recurrence of gastroesophageal reflux disease, recurrence of hernia and reoperation when no fundoplication is performed during a paraesophageal hernia repair but a lower risk of dysphagia, but none of these reached statistical significance.(Comment 1) Paraesophageal hernia repair with fundoplication should be performed, but it is acceptable to not do it in certain situations.

UNASSIGNED: To review management controversies in paraesophageal hernia and options for surgical repair.
UNASSIGNED: Paraesophageal hernia is an increasingly common problem. There are controversies over whether and when paraesophageal hernias should be surgically repaired. In addition, if these hernias are to be repaired, the method of repair, need for mesh reinforcement, need for fundoplication, and need for gastropexy are not uniformly accepted.
UNASSIGNED: Recent literature was reviewed on need for repair, approach (open, laparoscopic or robotic surgery), method of repair (primary suture, use of relaxing incisions, use of mesh reinforcement), materials and configuration of mesh reinforcement, need and type of fundoplication, and need for gastropexy, with emphasis on surgical outcomes.
UNASSIGNED: The extant literature suggests that paraesophageal hernia should be approached in a patient-centered, precision medicine manner. In general, hernia reduction, sac excision and primary suture approximation of the hiatal crura are mandatory. Use of mesh should be based on individual risk factors; if mesh is used, biological meshes appear to have a more favorable safety profile, with the \"reverse C\" or keyhole configuration allowing for increase in crural tensile strength at it most vulnerable areas. Use and choice of fundoplication or magnetic sphincter augmentation should be based on individual considerations. Finally, gastropexy is generally ineffective and should be used only in extreme circumstances.

BACKGROUND: Paraesophageal hernias (PEH) present with a range of symptoms affecting physical and mental health. This systematic review aims to assess the quality of reporting standards for patients with PEH, identify the most frequently used quality of life (QOL) and symptom severity assessment tools in PEH and to ascertain additional symptoms reported by these patients not captured by these tools.
METHODS: A systematic literature review according to PRISMA protocols was carried out following a literature search of MEDLINE, Embase and Cochrane databases for studies published between January 1960 and May 2020. Published abstracts from conference proceedings were included. Data on QOL tools used and reported symptoms were extracted.
RESULTS: This review included 220 studies reporting on 28 353 patients. A total of 46 different QOL and symptom severity tools were used across all studies, and 89 different symptoms were reported. The most frequently utilized QOL tool was the Gastro-Esophageal Reflux Disease-Health related quality of life questionnaire symptom severity instrument (47.7%), 57.2% of studies utilized more than 2 QOL tools and \'dysphagia\' was the most frequently reported symptom, in 55.0% of studies. Notably, respiratory and cardiovascular symptoms, although less common than GI symptoms, were reported and included \'dyspnea\' reported in 35 studies (15.9%).
CONCLUSIONS: There lacks a QOL assessment tool that captures the range of symptoms associated with PEH. Reporting standards for this cohort must be improved to compare patient outcomes before and after surgery. Further investigations must seek to develop a PEH specific tool, that encompasses the relative importance of symptoms when considering surgical intervention and assessing symptomatic improvement following surgery.

The use of mesh in laparoscopic hiatal hernia repair (LHHR) remains controversial. The aim of this systematic review was to determine the usefulness of mesh in patients with large hiatal hernia (HH), obesity, recurrent HH, and complicated HH. We performed a systematic review of the current literature regarding the outcomes of LHHR with mesh reinforcement. All articles between 2000 and 2020 describing LHHR with primary suturing, mesh reinforcement, or those comparing both techniques were included. Symptom improvement, quality of life (QoL) improvement, and recurrence rates were evaluated in patients with large HH, obesity, recurrent HH, and complicated HH. Reported outcomes of the use of mesh in patients with large HH had wide variability and heterogeneity. Morbidly obese patients with HH should undergo a weight-loss procedure. However, the benefits of HH repair with mesh are unclear in these patients. Mesh reinforcement during redo LHHR may be beneficial in terms of QoL improvement and hernia recurrence. There is scarce evidence supporting the use of mesh in patients undergoing LHHR for complicated HH. Current data are heterogeneous and have failed to find significant differences when comparing primary suturing with mesh reinforcement. Further research is needed to determine in which patients undergoing LHHR mesh placement would be beneficial.

BACKGROUND: Cameron lesions (CL) are an under-recognized cause of gastrointestinal bleeding. Diagnosis is often impaired by technical difficulty, and once diagnosed, management remains unclear. Typically, patients are medically managed with proton pump inhibitors (PPI). Small studies have demonstrated improved therapeutic success with surgical management, hypothesizing that reversing mechanical gastric trauma and ischemia allows CL healing. This systematic review and meta-analysis aim to compare therapeutic success of surgical versus medical management of Cameron lesions (CL).
METHODS: A comprehensive search and systematic review selected manuscripts using the following inclusion criteria: (1) Endoscopically diagnosed CL (2) Treated surgically (3) Follow-up for resolution of anemia or CL (4) n ≥ 5 (5) Excluding non-English, animal, and studies with patients < 18 years old Meta-analysis was performed to compare resolution of CLs with medical and surgical therapy.
RESULTS: Systematic search retrieved 1664 studies, of these, 14 were included (randomized controlled trial = 1; prospective = 2; retrospective = 11). Patients had a mean age of 61.2 years (range 24-91) and were more often female (59.3%). Follow-up was between 3 and 120 months, and 82.9% of patients had hernias > 5 cm. Surgical management was associated with therapeutic success (OR 5.20, 1.83-14.77, I2 = 42%, p < 0.001) with 92% having resolution, compared to 67.2% for those treated with PPI. Surgical complications occurred in 42/109 (38.5%) of patients (48.1% for Open Hill Repair, 15.4% for laparoscopic fundoplication). 40.0% of patients underwent a laparoscopic Nissen or Collis fundoplication, 21.7% underwent open modified Hill repair, and 38.3% had unspecified operations. Hemoglobin improved from 8.85 g/dL pre-operatively to 13.60 g/dL post-operatively. In six studies, surgical patients previously failed medical management.
CONCLUSIONS: This is the first systematic review comparing surgical and medical treatment of CL. Surgical management significantly improved therapeutic success. Our study supports therapeutic benefit of surgery in these patients.

Giant hiatal hernia (GHH) is a condition where one-third of the stomach migrates into the thorax. Nowadays, laparoscopic treatment gives excellent postoperative outcomes. Strangulated GHH is rare, and its emergent repair is associated with significant morbidity and mortality rates. We report a series of five cases of strangulated GHH treated by a minimally invasive laparoscopic and robot-assisted approach, together with a systematic review of the literature.
During 10 years (December 2009-December 2019), 31 patients affected by GHH were treated by robot-assisted or conventional laparoscopic surgical approach. Among them, five cases were treated in an emergency setting. We performed a PubMed MEDLINE search about the minimally invasive emergent treatment of GHH, selecting 18 articles for review.
The five cases were male patients with a mean age of 70 ± 18 years. All patients referred to the emergency service complaining of severe abdominal and thoracic pain, nausea and vomiting. CT scan and endoscopy were the main diagnostic tools. All patients showed stable hemodynamic conditions so that they could undergo a minimally invasive attempt. The surgical approach was robotic-assisted in three patients (60%) and laparoscopic in two (40%). Patients reported no complications or recurrences.
Reviewing current literature, no general recommendations are available about the emergent treatment of strangulated hiatal hernia. Acute mechanical outlet obstruction, ischemia of gastric wall or perforation and severe bleeding are the reasons for an emergent surgical indication. In stable conditions, a minimally invasive approach is often feasible. Moreover, the robot-assisted approach, allowing a stable 3D view and using articulated instruments, represents a reasonable option in challenging situations.

Despite paraesophageal hernias (PEH) being a common disorder, several aspects of their management remain elusive. Elective surgery in asymptomatic patients, management of acute presentation, and other technical aspects such as utilization of mesh, fundoplication or gastropexy are some of the debated issues. The aim of this study was to review the available evidence in an attempt to clarify current controversial topics. PEH repair in an asymptomatic patient may be reasonable in selected patients to avoid potential morbidity of an emergent operation. In acute presentation, gastric decompression and resuscitation could allow to improve the patient\'s condition and refer the repair to a more experienced surgical team. When surgical repair is decided, laparoscopy is the optimal approach in most of the cases. Mesh should be used in selected patients such as those with large PEH or redo operations. While a fundoplication is recommended in the majority of patients to prevent postoperative reflux, a gastropexy can be used in selected cases to facilitate postoperative care.

Robotic Surgery is becoming increasingly used in general surgery. The objective of this study is to evaluate the safety, effectiveness and short-term (less than 1 year) outcomes of Robotic Paraesophageal Hernia (RPEH) Surgery using the DaVinci Surgical Robot system (Intuitive Surgical, CA) in a large community hospital. This is a retrospective cohort study of 28 consecutive patients who underwent robotic paraesophageal hernia repair January 2011-March 2013 in this institution. Data and outcomes collected for analysis include patient demographics, operating times, conversion, complications, mortality and recurrence. The mean age of the patients was 68.7 +/- 12.7 years, 82% were females and the mean BMI was 29 +/- 6.3. The mean operative time, including the robot docking time, was 83.6 + 24 min. The average length of hospital stay (LOS) was 2.8 +/- 1.9 days. There were no conversions to open or laparoscopic procedures. Postoperative complications were noted in 3 patients (10.7%), including one mortality (3.4%). One symptomatic recurrence (3.4%) was noted during the 12-month follow-up period. Robotic Paraesophageal repair is a safe (similar rate of complication and mortality to literature for laparoscopic procedure) and an effective (paraeshopageal hernia repaired without high recurrence) procedure with acceptable complication rates even in older patients with high operative risks.